The Role of Intraoperative Functional Lumen Imaging in Peroral Endoscopic Myotomy and Laparoscopic Heller Myotomy

Peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) are 2 common treatments for achalasia. Endoluminal functional lumen imaging probe (EndoFLIP; Medtronic) technology allows for real-time esophagogastric junction measurements intraoperatively before and after myotomy. We hypothesize that POEM would result in improved distensibility over LHM given its longer myotomy length.

A retrospective cohort study of prospectively collected data from consecutive patients with achalasia who underwent either POEM or LHM at a single-center tertiary care center between 2018 and 2019 was performed. Premyotomy and postmyotomy EndoFLIP measurements and outcomes such as length of stay and 30-day readmissions were compared using χ² and t tests.

Data from 65 patients with achalasia were included (19 LHM and 46 POEM), and 57 patients were excluded for lack of EndoFLIP data. The POEM cohort was significantly older (P < .001), with no other significant demographic differences. Average pre-LHM and post-LHM distensibility (1.22 [SD 0.5] and 3.64 [1.14], respectively) represented a mean 198% ( 41%) increase. Pre-POEM and post-POEM distensibility measurements (1.73 [1.41] and 4.1 [2], respectively), demonstrated a mean 137% (39%) increase (P = .95). The esophagogastric junction diameter increased by 73% (42%) and 49% (41%) in LHM and POEM, respectively (P = .07). There was no significant difference in length of stay (P = .06) or 30-day readmissions (P = .17).

Similar increases in EndoFLIP measurements were seen intraoperatively during POEM and LHM. Longer-term quality of life data should be used to correlate with EndoFLIP measurements to understand the benefits of myotomy.